A Study on Prevalence of Bacteria in the Hands of Children and Their Perception on Hand Washing in Two Schools of Bangalore and Kolkata

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1 Original Article A Study on Prevalence of Bacteria in the Hands of Children and Their Perception on Hand Washing in Two Schools of Bangalore and Kolkata *Sandip Kumar Ray 1, Ritvik Amarchand 2, Jayanthi Srikanth 3, Kunal Kanti Majumdar 4 1 Professor and Head, 4 Associate Professor, Department of Community Medicine, KPC Medical College, Kolkata, 2 SRO, Centre for Community Medicine, AIIMS, New Delhi, 3 Associate Professor, Department of Community Medicine, Kempegowda Institute of Medical Sciences (KIMS), Bangalore, India Abstract Background: Contaminated hands play a major role in fecal oral transmission of diseases. In 1847, Dr Semmelweis Ignac pointed to the link between infection and unclean hands, and demonstrated that washing hands could reduce transmission of puerperal fever (child birth fever), a dreaded disease with high mortality in those days. Materials and Methods: A cross-sectional study was conducted to fi nd out the extent of germs present in hand, and also the students perception on hand washing. This was assessed by questionnaire as well as by collection of swab from hand and performing bacteriological culture in the laboratory. Results: In regard to students perception about the dirty areas of the hands, it was observed that majority (78%) felt palm was likely to be more dirty while less than 70% felt that web spaces could harbor dirt. Almost 86% reported that they washed hands before eating lunch, but only 21.3% said they always used soap while 47.3% never used it. Availability of soap all the time in the school was reported by only 18.4% students. The swabs of 61% children showed potential pathogens. The commonest of these was Staphylococcus aureus which was seen in 44% samples. Conclusion: The students hands were contaminated before taking food. Although they washed hands before meals, they hardly used soap due to non-availability of soap. The school authority should be asked to keep soaps in the toilets for hand washing. Key words: Handwashing, Prevalence of bacteria, Students, Perception Introduction Contaminated hands play a major role in fecal oral transmission of diseases. In 1847, Dr Semmelweis Ignac pointed out the link between infection and unclean hands, and demonstrated that washing hands could *Corresponding Author: Dr. Sandip Kumar Ray, Professor and Head, Department of Community Medicine, KPC Medical College, Kolkata, India. sandip89@hotmail.com Website: DOI: / X PMID: *** Access this article online Quick Response Code: reduce transmission of puerperal fever (child birth fever), a dreaded disease with high mortality in those days. 1 Since then, a number of studies have established that hands can carry different types of pathogenic organisms. Washing hands is believed to reduce infection transmission by washing off potential microorganisms and also by removing the dirt, which could also harbor microorganisms and allow their survival for longer periods of time. 2 Systemic reviews have pointed the effectiveness of hand washing in reduction of diarrhea 3,4 and acute respiratory illnesses, 5,6 the two major childhood killer diseases. Despite being shown to be effective, hand washing with soap is not a common practice. Worldwide, there is a wide variation in the prevalence of hand washing behavior and the use of soap for hand washing is not widespread. 7 A study 8 conducted in West Bengal among 302 respondents from rural, urban slums and non-slum areas revealed that in the urban slums, 98% reportedly washed hands with soap after defecation, while only 69% did so after cleaning child s bottom. In

2 294 rural areas, 71% washed hands with soap after defecation while 26% used mud or ash; however, only 5% used soap after cleaning child s feces. As the practice of hand washing is poor, isolation of pathogenic microorganisms has been reported in a number of studies done among children. A study from Greece 9 found that 52.9% of children s hands of the 1956 hand swab samples were contaminated by fecal streptococci. A study from Amravati, Maharashtra, 10 demonstrated the presence of bacterial pathogens in the hands of all of the 400 students whose hand swabs were examined. Data on hand contamination from India are limited. This study was designed keeping in mind the need for studies to look at the prevalence of hand contamination among school children. The objectives of the study were as follows: 1. To find out of the prevalence of bacterial contamination of hands of school children before taking mid-day meals 2. To understand the perception of school children on key issues of hand washing Materials and Methods The study was conducted by Indian Public Health Association with the involvement of KPC Medical College and Hospital, Jadavpur, Kolkata, and Kempegowda Institute of Medical Sciences, Bangalore. Two urban schools, one each from Bangalore and Kolkata, were selected (by convenience), and 100 children and 108 children (total 208 children), respectively, aged approximately years, i.e. in classes 6 th to 8 th, were selected for the study from each of the above schools. Very few were above this age group but studying in these classes only. The study was cleared by the ethics committees of the two participating institutes. Written consent was taken from the schools as well as from the parents of the students of the selected classes. On the pre-decided days (for 3 4 consecutive days), a visit was paid to the selected classes when the children had no knowledge about such study. The visit was paid an hour preceding the mid-day meal time. A station to take hand swabs as per standard aseptic procedures was established. Dominant hand of the child was swabbed, beginning from the flexor aspect of wrist, across palm and up all the five fingers (beginning with thumb) including the creases and nail beds, ending in the dorsal aspect. A standardized questionnaire was used to fill some basic information related to hand washing by paramedical workers under the supervision of faculty member of Department of Community Medicine and Microbiology of the above medical Colleges. The ID number of the swab was pre-filled on the questionnaire so as to enable linking the findings, if required. The questionnaire included the issues like practice of hand washing before meals and after defecation, material used for washing hands, hand washing facilities at home and school, availability of water and soap at such facilities, importance of hand washing and students perception about dirty areas of the hand. The swabs were collected in Amies Transport Media swabs (Himedia) and transported to lab within 1 2 hours. At the lab, inoculation was done on urochrome UTI agar and blood agar. After 24 hours of incubation, the following pathogens were identified: Enteric bacteria or coliforms like Escherichia coli, Klebsiella, Enterobacter, Proteus, enterococci- (diarrheal diseases) detection by characteristic colored colonies on urochrome agar Staphylococcus aureus (diarrheal + respiratory + skin diseases): detection by colonies on urochrome and blood agar, Gram stain and coagulase test Pneumococci, Group A streptococci (respiratory diseases): detection by colonies on blood agar and Gram stain morphology Subculture on special media + biochemical tests if suspicion of Salmonella or Shigella (enteric and diarrheal diseases) Usually non-pathogenic commensals like coagulasenegative staphylococci, viridans streptococci, diphtheroids, Candida sp. detection by colonies on urochrome and blood agar + Gram stain Usually non-pathogenic environmental flora like Micrococcus sp., Bacillus sp., Pseudomonas sp., Acinetobacter sp. detection by colony morphology on urochrome and/or blood agar and/or Gram stain Data entry and analysis: Data were entered in Epi-Info (version 3.4.1) and frequency distribution of the different variables was noted.

3 295 Results A total of 208 children were included in the study. Both questionnaires were filled in and swabs were taken. Among the study participants, 161 (77.4%) were females. The mean age of the children was 12.8 years, with a range of 9 19 years. In regard to students perception about the dirty areas of the hands, it was observed that majority (78%) felt palm was likely to be more dirty while less than 70% felt that web spaces could harbor dirt [Table 1]. Almost 86% of children reported that they always washed their hands before eating lunch. It was interesting to note that 47.3% students never used any soap while 30.9% students used it occasionally and only 21.3% always used soap for hand washing. Regular hand washing before taking dinner was reported by 88% children. 52.2% said that they always used soap for hand washing before taking dinner. It was reported by 97.6% of the students that they always wash hand after defecation, while only 72.9% of them Table 1: Students perception of the dirty areas of the hands Contaminated areas of the hands Numbers of students Percentage * Palm Fingers Finger tips Nails Web spaces Dorsum of the hand * Multiple responses used soap. About 97% students said that they had hand washing facilities near toilets at their homes and 85% of such facilities were provided with soap. Around 99.5% students reported that hand washing facility was present near the toilet of their own schools and only 18.4% of these toilets were provided with soap [Figure 1]. It was reported that handkerchief was used by 63% of children for drying hand. It was reported by 52.4% of students that they used soap while washing hands on the last occasion. On the contrary, 46.6% of the participants said they did not use soap when they last hand washed [Figure 2]. In regard to the importance of hand washing, about 33.2% of the children said that it removes dirt and makes the hands clean, 40% said it prevents diseases and keeps them healthy, and 51.4% children said that hand washing should be done as hands have germs and hand washing removes the germs. There were multiple answers by each individual student. Hand swabs were taken from all the 208 students. The swabs of 127 (61%) children revealed potential pathogens. The commonest of these was S. aureus which was seen in 44% of samples. This bacterium is associated with skin and respiratory diseases as well as food poisoning. The commonest coliform bacterium noted was Enterococcus faecalis: in 49 (24%) samples, followed by E. coli in 25 (12%) samples and Klebsiella sp. in 14 (7%) samples. Presence of Group A streptococcus, which is a potential respiratory and skin pathogen, was noted in 5 (2.4%) samples. Commensal flora growth, which is generally non-pathogenic to immunocompetent individuals, Figure 1: Availability of soap at hand washing facility at school Figure 2: Use of soap for washing hands on the last occasion before the hand swab was taken

4 296 was noted in 76 (36.5%) samples. The findings are summarized in Table 2. Discussion The study demonstrated the presence of pathogenic microorganisms on the hands of 61% of the children studied. The study from Amravati, Maharashtra, had also demonstrated the presence of potential pathogens on hands of students between 3 years (Kindergarten) and 24 years (Postgraduates), studying in various educational institutes. The isolates included Staphylococcus sp. (23%), E. coli (20%), Klebsiella sp. (10%), Micrococcus sp. (9%), Proteus sp. (7%), Citrobacter sp. (7%), Streptococcus sp. (7%), Enterobacter sp. (6%), Enterococcus sp. (4%), Pseudomonas sp. (3%) and Salmonella sp. (2%). The authors also demonstrated reduction in hand contamination after hand washing. 10 In the current study, practice of hand washing was found to be high; however, soap usage was found to be suboptimal, as has been seen in other studies from other countries. 7 The present study findings are similar to a study 11 on knowledge, attitude and practices of school children conducted in Ethiopia, which found that though most students reported hand washing before meals, i.e. 99.0%, only 36.2% reported using soap during hand washing. Availability of soap at handwashing facilities, especially in schools, was low. This study more or less corroborated with the present study findings. About 50% children exhibited the knowledge that hand washing removes germs. About 30% children did not know that nails or web spaces can be dirty areas in hands. Further, the present study also corroborated with the other studies on bacterial content in hands as well as diseases caused by the improper hand washing practices. Ray et al., 12 observed a decrease in colony count following hand washing with soap in 60% of the samples in a study conducted in areas around Kolkata. The evidence suggested that hand washing with soap reduced the bacterial count in majority of the respondents. At the same time, an increase in colony count was seen in 30% samples that were either pond water users or food servers from a canteen using dirty clothes for drying hands after washing. Therefore, to have a real impact, particularly in reducing the incidence of diseases, three aspects of hand washing seem to be important: washing hands with soap and following all steps diligently, using clean water and drying hands with a clean cloth. A study in Karachi, Table 2: Distribution of isolates from hand swabs according to the nature of the organism Pathogens identified Pakistan, 13 has demonstrated that regular hand washing and bathing with soap is effective in preventing both diarrhea and pneumonia. Another study from Kolkata slums indicated that hand washing with soap may reduce the incidence of dysentery cases in the community. 14 Conclusion Bangalore (N = 108) The students hands were contaminated before taking food. Although they washed hands before meals, they hardly used soap due to non-availability of soap at schools. Children are often targeted for hygiene behavior as it is felt that habits that develop at their impressionable age would continue into their adulthood. However, in the absence of infrastructure which includes water and soap for hand washing, inculcating this habit would not be possible. It was found that the students hands were contaminated before taking food. The schools should be told to keep soaps in the toilets for hand washing. Schools should help in this regard which is not a costly affair. However, teachers should tell the students that drying hand after washing with soap should be done by clean dry clothes, otherwise effect of hand washing with soap will be lost and students will suffer from diarrhea dysentery and pneumonia even after hand washing. Acknowledgments Kolkata (N = 100) Total (N = 208) Potential pathogens 62 (57.4) 65 (65) 127 (61) Staphylococcus aureus 41 (37.96) 51 (51) 92 (44) Escherichia coli 20 (18.51) 05 (05) 25 (12) Enterococus faecalis 13 (12.03) 36 (36) 49 (24) Klebsiella 04 (3.70) 10 (10) 14 (7) Commensal flora 48 (44.44) 29 (29) 77 (37) Sterile culture None 06 (06) 06 (3) Figures in parentheses are given in percentage Authors deeply acknowledge Lifebuoy of Hindustan Lever limited (HLL) for the support rendered for carrying out the study with an intention to improve hand washing practices among the school children, in collaboration with Indian Public health Association. The authors also acknowledge with gratitude the respective Principals of KPC Medical College, Kolkata, and Kempegowda Institute of Medical Sciences (KIMS), Bangalore, for permitting them to conduct the study as well as for ethical clearance.

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